Worries About Scarring
Do you want breast augmentation but are afraid of the scars? You’re not alone! Pain and scars are the two biggest obstacles patients fear when considering cosmetic surgery.
There is no way to place a breast implant without leaving a scar, HOWEVER, a skilled plastic surgeon is able to do it in a way that will hide those scars incredibly well.
Minimal scarring is a necessary trade-off for augmentation. Although an incision scar will appear, a well-healed scar will fade to virtually invisible over time. I generally tell my patients that scars will take a full year to mature.
A board-certified plastic surgeon will also follow certain principles to minimise scarring:
- Choose a sufficient incision length for pocket access and implant insertion
- Reduce trauma to the skin edges during surgery
- Choose the right incision placement to reduce tension or stretch on the incision
- Use delicate incision closing techniques to minimize tension on the skin
Following these principles will produce high-quality scars (i.e. they will barely be visible)
Nevertheless, scarring predominantly depends on 2 things – Incision placement, and incision length. As no two patients are alike, it’s important to individualise the surgical plan for each patient’s specific needs.
There are three main incision options which are: inframammary, transaxillary, and peri-areolar. Each have their own merits as detailed below but the best incision should minimise scarring, allow safe pocket creation, and permit a safe implant insertion.
This is carried out in the breast fold and is the most widely used incision site.
Specific advantages include:
- Provides great amount of direct vision and surgical control on variables like bleeding.
- There is less trauma to surrounding tissues (e.g., breast tissue, milk ducts, critical nerves, and blood vessels) during pocket dissection and implant insertion
- All types of implants can be inserted through this approach
- In case revision surgery is required in patient’s lifetime, a new incision is not required
- Allows controlling of the inframammary fold to provide a natural look
- A presence of the scar on the aesthetic unit of the breast
- Not suitable if there is areolar asymmetry or areolar herniation as there is in the tuberous breasts
- It is best suited for patients who have a small areola (dark pigmented skin around the nipple), patients with breast sagging, and those who require large volume implants or form-stable implants
The axillary incision approach is most suitable for patients who have great concerns about having a scar on the breast, by placing the scar on the armpit instead. The axillary approach requires patients have sufficient breast tissue and normal breast shape. This approach can also be used if the patient has a small areola or only requires small silicone or saline implants. In fact, this is ideal for patients with very youthful-appearing breasts, especially younger women with no history of pregnancy and those who have smaller, perkier breasts.
Specific advantages include:
- Lesser trauma to surrounding breast tissues while dissecting an implant pocket
- With the proper no-touch technique using the Keller Funnel, the rate of capsular contracture is very minimal
- This approach only provides direct visual access to the upper half of the implant pocket and full vision dissection requires an endoscopic camera
- Critical nerves and blood vessels near the armpit can be injured if excessive dissection is done
- If re-operations are required, an additional incision using the inframammary or peri-areolar approach is required to optimize control and accuracy
- The axillary approach is not good for patients with tuberous breasts, constricted breasts, or with severe sagging
- This approach has an increased risk for implant malposition in the upper pole of the breast because of poor visualization of the inframammary fold
- Great caution is required to prevent trauma to lymphatic vessels which are part of our immune system
In this approach, the incision is made around the areola (the dark pigmented skin around the nipple) and carried directly through the breast tissue. Even though this approach gets used less often, it can be very useful to avoid a scar in the fold of the breast. This is especially true if there is distinct border and colour difference between the areolar skin and the surrounding breast skin. This will allow the scar to be concealed within the dark pigmented areola.
Specific advantages include:
- Excellent access for direct vision and control surgical variables and pocket dissection in all areas
- Easier correction of areolar asymmetries, deformities, or nipple-areola malpositions
- All types of implants can be placed given the diameter of the areola is adequate
- There are very few critical nerves or blood vessels in close proximity to the incision site
- Form-stable silicone gel implants are more difficult to place with greater risks of implant damage
- Breast tissue is dissected resulting in more trauma comparatively
- During insertion, the implant is exposed to breast tissue bacteria resulting in higher rates of infection and capsular contracture.
- Breasts are more likely to face interference with breastfeeding and sensation
- Great care is needed to maintain blood supply to the nipple-areolar complex
- The approach is not suitable for those with small areolas as it will put limitations on vision, control, and implant insertion
- The scar is located on the most visible portion of the breast
- Because dissection is made through the breast tissue, there is a risk of the implant herniating through the breast tissue tunnel.
When deciding on the incision placement, you have to consider your own preference, the surgeon’s skill in the specific approach, and the degree of visibility and control over surgical variables and pocket dissection.
The incision should also allow insertion of the implant without any damage or contamination to the implant or any damage to the surrounding breast tissue. In the end, you must collaborate with your surgeon to select the incision approach that best suits your body and your needs.
Irrespective of where the cut is made, the incision length is the second factor that influences the scar. This is also further related to the implant type and size of implant chosen to use.
Many surgeons try to attract patient with claims over “shorter scars” but the truth is that a smaller incision decreases the surgeon’s field of vision. This makes surgical manoeuvres and insertion of pre-filled silicone implants much more difficult resulting in poor quality scars compared to longer scars.
Of course, no surgeon will want to make an excessively long incision, or else you will not be happy with your results.
How long Is A Standard Incision
Incisions with silicone round implants have to be around 4-6 cm. For anatomical cohesive silicone implants, this will need to be slightly larger. By comparison, incisions can be made around 3.5-4.5 cm for saline implants because they are not pre-filled but rather inflatable. There is always the option of having your implants inserted through the Keller Funnel which is the technique I use to reduce the length of the required incision.
On a side note, any incision less than 3.5 cm is a set-up for more trauma, scars, re-operations, and damage to the implant. Longer incisions are always preferable to short incisions that subject the implant to much greater pressures during insertion.
How Obvious Is The Scarring Directly After Operating
With regards to concerns of a scar showing in your swimsuit, either the inframammary incision or the peri-areolar incision could do to some small extent. The transaxillary incision will be visible under your armpit though, especially when you lift your arms.
The inframammary incision is usually not visible when standing or sitting upright, and because the incision will be placed just above the fold, it will be facing down making it less noticeable. It is also less likely to be under tension as this region does not tend to stretch or be raised. IMF scar will be hidden in bras and even under triangle-top string bikinis and is only visible up close when the breasts pulled upwards revealing the breast fold.
However, if you make raised scars, they may be visible beneath the tight shirt or through a bathing suit in both cases of periareolar or inframammary.
Treatment of abnormal scars
Let us suppose you have raised scars. In which case, there are many things you can do to improve your scar. You may:
- Gently massage it using a lubricating cream containing Aloe Vera and Vitamin E for 6-12 weeks
- Use a topical skin solution that contains a silicone solution such as a scar guard
- Avoid wearing underwire bras, exposure to direct sunlight on the incision, or exercises that will stretch the incision area
Of course, you should also regularly see your surgeon for follow-ups. In more serious cases, steroid injections or steroid-containing skin tap can be used to flatten raised scars. Because of the potential steroid side-effects, Intense Pulsed Light can be effective at reducing redness in wounds.